Healthcare Provider Details

I. General information

NPI: 1033346317
Provider Name (Legal Business Name): DAVID TAI WAI WONG DMD, DMSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE 73-017 CHS
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

10833 LE CONTE AVE 73-017 CHS
LOS ANGELES CA
90095-3075
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-3048
  • Fax: 310-825-7609
Mailing address:
  • Phone: 310-206-3048
  • Fax: 310-825-7609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number51420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: